Introduction
Parental substance misuse undermines the individual’s ability to parent well and consistently. The importance of parenting for both the current adjustment and later development outcomes of children has been well established (see Section 2). More recently, improvements in research design have permitted a more thorough examination of the pathways from child-rearing history to later parenting (Belsky et al, 2005; Capaldi et al, 2003; Confer et al, 2003). These studies provide good evidence for what many scientists, practitioners and the lay public have suspected: that patterns of parenting and discipline that parents use with their children can be at least partially predicted from those their own parents used (e.g. Belsky et al, 2005; Conger et al, 2003). The evidence is that productive aspects of parenting such as parental monitoring, involvement, consistent discipline and warm parent-child relations lead to similar constructive parenting behaviours in the subsequent generation by supporting youth achievement, self-esteem and positive peer relations (Kerr et al, 2009).
These studies suggest that what is being transmitted to children through supportive and consistent environments may not be parenting behaviours per se, but a host of cognitive and interpersonal skills that are applied to functioning parenthood. These skills are also applied to other roles in our adult lives, such as of employee, colleague, neighbour, etc.
The international literature identifies a number of important programmes, projects and
interventions that help to buffer the risk and/or address the impact of parental substance misuse. Many of these activities have an adult- rather than a child or family-focus and many that are child- focused carry punitive connotations. Based on the main findings from the literature set out in this report, this section discusses the implications for responding. The message from the general literature is very clear in one respect: the earlier the intervention the better and the more disadvantaged the child, the more powerful the effects of the intervention. The following section
reviews what steps are taken when responding to parental substance misuse and cover working with the child’s adult/parents, the child’s family and finally the wider community.
5.1 Supporting the parent
and family
5.1.1 Prenatal and perinatal stages and
substance-use dependency
Section 2 of this report highlighted that pre-natal consumption of drugs and alcohol can have serious consequences for the health and development of the foetus. This risk varies with the pattern and quantity consumed by the mother. Consequences include neo-natal abstinence syndrome (NAS) and/or foetal alcohol spectrum disorder (FASD). Despite public health campaigns and improved knowledge about the harmful effects of alcohol intake during pregnancy, many pregnant women in Ireland do not abstain from drinking during pregnancy (Donnelly et al, 2008).
Alcohol use can also be detrimental for pregnancy women in drug treatment. Alcohol use is high among women on methadone maintenance treatment, (Teplin et al, 2007) and this has also been found for Ireland (Ryder et al, 2009). Alcohol use is not only associated with poorer treatment outcomes, but is also a leading cause of death for patients in substance-use treatment (Joseph et al, 1985). Research shows that one of the reasons women drink is to help cope with stress. Pregnancy and the perinatal stages are
particularly vulnerable times, with increased risk for triggering stress and derailing treatment, which has consequences for the mother-child relationship.
Primary Care Teams: In this regard many studies comment on the desirability of collaborative care between primary care and addiction services. Given that many women in Ireland do not abstain from alcohol when pregnant (Williams et al, 2010), priority needs to be given to interventions that address problem alcohol use among those
Parents misusing drugs and alcohol can jeopardise child and family well-being and can undermine the potential of families to meet children’s developmental, health and welfare needs. Recognising these challenges, the NACD, HSE and Alcohol Action Ireland come together in this seminar to consider how policy and services can be more effective in supporting children in families where there are drug and alcohol problems. The seminar aims to:
who avail of support and treatment from primary care (Ryder et al, 2009). Primary healthcare practitioners are in a unique position to recognize patients with potential alcohol and drug problems and to provide interventions and/or referrals where appropriate.
Those with substance-use problems most frequently engage with primary healthcare providers (Narrow et al, 1993) and, hence, the primary care team (PCT) is well placed to provide initial assessments, brief interventions and referrals for pregnant women. Primary care is especially important for these women’s children as it is where early intervention happens. The underlying rationale of the PCT is providing a person-centred primary-care service through multidisciplinary teams and networks, serving defined populations (Primary Care Strategy, 2001). Through the PCTs, children and/or parents have access to a range of services. These include the GP and public health nurse, while integral to the service is the provision of a range of therapeutic services in one centre. These services include speech and language therapy, occupational therapy, counselling and social work, which are critical for children, often providing the early intervention necessary to prevent the escalation of problems. If well-resourced, a responsive and effective primary-care service could prevent the development of problems that may later require more intensive interventions.
For parents and pregnant women who misuse substances, screening, assessment and a continuum of care is very important for their own health and that of their children. This quality of care depends on professional awareness, skills and the knowledge to identify the impact of parental substance misuse on children (e.g. foetal alcohol spectrum disorder). A recent report (Encare, 2010) recommends that medical professionals in Ireland, including GPs and public health nurses, should be informed and updated on the advice of the Chief Medical Officer regarding alcohol use during pregnancy to enable them to raise their patients’ awareness of the risks.
Problem substance use is associated with health problems, serious mental illness and higher stress, and for women, a greater likelihood of being a victim of interpersonal violence. Addressing substance use and mental-health problems in primary-care settings helps to reduce the stigma associated with these problems. This should increase people’s access to services as it represents a first point of contact to the health system and social services for women with substance-misuse problems, but also for relatives affected by substance-abuse issues, who are not linked into existing services. In this way the PCT could provide timely and effective support for children and families.
However, in Ireland primary (and secondary care) services are configured to give advantage to those with the lowest health needs (Sinclair cited in Chan et al, 2011). People who misuse substances are disadvantaged in many respects, being unemployed, being of poorer health and mental health, and having relatively low levels of
education. A recent study focusing on the problem of access to primary care in deprived areas found that the use of lengthened consultations did not result in better health, mental health or quality of life among mothers living in the areas in question (Chan et al, 2011). The authors suggest there is a need in these areas to develop stronger
collaboration with mental-health services. This study did not measure team-building, but poor collaboration among PCT members would undermine team consultation and consequently the capacity to recognise and assess problems. Widely recognised inhibitors to collaboration of this type include issues related to change and the process of care. Resistance to change, new staff and new roles, and balancing competing demands can be difficult to overcome without strong leadership that is committed to integrated care and that champions the programme.
5.1.2 Treatment service providers
supporting the parent and family
Treatment for substance dependency can lead to withdrawal symptoms, with substantial physical and emotional distress. The process also entailsParents misusing drugs and alcohol can jeopardise child and family well-being and can undermine the potential of families to meet children’s developmental, health and welfare needs. Recognising these challenges, the NACD, HSE and Alcohol Action Ireland come together in this seminar to consider how policy and services can be more effective in supporting children in families where there are drug and alcohol problems. The seminar aims to:
vast behavioural and emotional changes. While achieving and maintaining abstinence is possible, it is a difficult process and one that is rarely straightforward. Psychological stress from work or family problems, social cues or the environment can interact with biological factors to hinder sustained abstinence and make relapse more likely. Despite the positive nature of substance-use changes, both children and parents frequently find change difficult. For example, a parent newly in recovery can finding coping with a child’s needs very difficult. Problems in family functioning may have developed over time and can be
overwhelming as the parent tries to engage with family. For children, their parents going through the treatment process and recovery can be traumatic, particularly as the family dynamic associated with substance dependence begins to change. Children experiencing a parent’s recovery may have trouble accepting the parent’s attempt to function in a role that he/she previously did not perform. Clearly, children can experience distress and at worst be at risk of harm in these
circumstances. Where family relationships have been affected by substance misuse, there is a need to (re-) develop quality relational ties between family members, strengthening connections and the basis for building trust. Treatment service providers supporting clients’ parenting responsibilities: The focus for adult addiction services has mainly been on building a helping relationship and a solid rapport with their clients. This has not included working either with the children or with the adult to enhance their parental responsibility. Yet treatment service providers can play an important role in supporting families under stress, including families where a child is at risk of significant harm. Of course safeguarding trust and respect is vital to the success of the therapeutic relationship between treatment provider and client. There are important benefits to be gained, as McConnell and McGivern22 suggest, when adult treatment service providers routinely screen for childcare responsibilities as part of the ongoing process of provision of treatment. By establishing the
22 Citing Harbin and Murphy (2000).
parenting status and the nature of childcare responsibilities of those availing of treatment services, they are better informed to ensure that treatment supports rather than undermines, or is undermined by, the demands of family care. Routinely screening clients’ childcare roles generates important information to assess family support need and for making referral decisions and strengthening the referral process involved. Treatment services involving the family: There are gains to be made from involving families and carers in relation to parental substance-misuse issues. Given the link between parenting and drug-treatment outcomes, a failure to do so could put both the service user and/or their children at risk. Treatment services have recognised for some time the difference that a supportive family can make to their clients’ wellbeing. As reviewed earlier in this report, where it is possible, involving family members in the recovery/ treatment process can be effective for many families affected by substance misuse. While it can be beneficial, it is nevertheless a challenge to engage family members in a process to (re-)establish relationships and family
connections. Children’s services and the interventions that aim to strengthen families focus on building reciprocal positive connections between family members. Treatment services, working with the relevant child/family agencies to integrate, for example, parenting and family communication skills will be an important step here. There is evidence that combining family- based interventions with substance-misuse treatment has positive effects on children who have substance-misusing parents when it builds family routines and promotes strong bonds to non-drug using family members (Dawe and Harnett, 2007). Where treatment providers work with family members, the latter are afforded the opportunity to learn about addiction, understand the impact of addiction on their relationships, and begin the process of change that is involved in their relative’s substance treatment. Many of the programmes of working with family members provide concrete skills and information that will
Parents misusing drugs and alcohol can jeopardise child and family well-being and can undermine the potential of families to meet children’s developmental, health and welfare needs. Recognising these challenges, the NACD, HSE and Alcohol Action Ireland come together in this seminar to consider how policy and services can be more effective in supporting children in families where there are drug and alcohol problems. The seminar aims to:
help family members to build on their existing strengths.
It is important to incorporate not only members of the immediate family but also of the extended family who can provide support for the child, and where appropriate, for the non-dependent parent. However, consideration must be given to
considering personal circumstances and limitations for support. For example while parenting grandchildren may be an emotionally rewarding experience, it also incurs psychological, physical and economic costs in performing these roles (Burton 1992; Minkler et al 1997). Important insights regarding these and other related issues should be gained from studying the work by community based services (examples in Dublin are Ballyfermot Star and Ballymun Youth Action Programme). The extent to which this is a part of the work and approach used with parents who for example are in treatment for substance misuse treatment has not been established in Ireland.